Run the tracheostomy emergency before it happens

Design

multi-institutional quality improvement and in situ simulation study with structured debriefs and multivariable Cox models

Population

67 baseline simulations of paediatric tracheostomy emergencies across inpatient floors, critical care units and emergency departments at 11 paediatric hospitals

Primary outcome

time to completion of critical actions, and identification of latent safety threats

Effect

77% replaced an identical tube within 5 minutes (median 188.4 seconds); median 3.2 latent safety threats per simulation; faster with a respiratory therapist present or a dedicated tracheostomy team

A blocked or displaced paediatric tracheostomy tube is a small number of minutes with no margin, and it happens in wards and emergency departments rather than in theatre. PEAK-II Trach ran in situ simulations of exactly that scenario - obstructed or partially dislodged tubes - across inpatient floors, critical care units and emergency departments at 11 paediatric hospitals, timing critical actions and debriefing structurally afterwards.

Across 67 baseline simulations, 77% of teams replaced an identical tracheostomy tube within five minutes, at a median of 188.4 seconds. Teams identified a median of 3.2 latent safety threats per simulation. The recurring ones are worth reading as a checklist of what to fix: attempted ventilation through an occluded tube, unclear leadership, ambiguous role definitions, and non-standardised equipment locations. Teams that included a respiratory therapist, and institutions with a dedicated tracheostomy team, performed the time-critical actions faster.

The reason this belongs at the end of an edition is that every item on that list is fixable this month and none of it requires evidence beyond its own logic. Standardise where the emergency box sits and what is in it, on every unit that admits a child with a tracheostomy. Write down who leads and who does what. And run the simulation in the actual clinical area rather than in a skills lab, because in situ is what surfaces the threats - a simulation in a training room will not tell you that the spare tube is kept in a different cupboard on the second floor.

• Run the simulation in situ, on the ward or in the department, not in a skills laboratory.
• Standardise the emergency box: same contents, same location, on every unit that admits these children.
• Assign leadership and roles out loud at the start of the emergency - ambiguity was among the commonest threats identified.
• Check that teams know not to keep ventilating through an occluded tube; it was a recurring latent threat.
• Include a respiratory therapist in the response team where you have one - teams with one were faster.

The statistics, in plain English

This is a quality improvement and simulation study, so the numbers describe team performance under observation rather than measured patient outcomes - teams knowing they are being timed generally perform better than they would at three in the morning, which makes 77% within five minutes a best case. The median of 3.2 latent safety threats per simulation depends on how thoroughly each debrief was conducted, so it is a count of what was found rather than of what exists. The associations with respiratory therapist presence and a dedicated tracheostomy team come from multivariable models across 67 simulations at 11 institutions, which is enough to indicate a direction and not enough to size the effect.

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